Intralesional Injection of Corticosteroids: A Lesson from Liposuction

Sir: Keloid and hypertrophic scarring are challenging problems, with numerous treatment modalities advocated.1 The injection of corticosteroids either in isolation or as an adjunct to excision has a low morbidity, is cost effective, and is frequently undertaken in the outpatient setting. Effective administration of intralesional corticosteroids requires an approach that overcomes the physical resistance posed by the scar. Injection into a thick scar usually necessitates use of high pressure and is painful for the patient.2 The higher pressures required to inject the contents of the syringe can lead to disconnection between needle and syringe. Furthermore, a lack of control, which has been associated with disposable, unlocked plastic systems, can occasionally result in the drug being injected into the subcutis, resulting in atrophy of the skin and subcutaneous fat. Previous authors have described how some of these difficulties can be overcome through use of a standard metal dental needle and syringe.3,4 In our experience, such approaches confer greater efficiency and control but still necessitate multiple punctures of the scar, particularly larger ones, to obtain an even distribution of steroid. We present a technique that harnesses the advantages of locked systems but furthers their application through combination with pretunneling of the scar tissue. Pretunneling makes administration of the steroid easier, ensures an even distribution, and requires fewer punctures of the scar. The required materials include a 25-gauge needle, a 2-ml Luer-Lock plastic syringe, and a steroid preparation (e.g., triamcinolone acetonide, 10 mg/ml). If local anesthetic is to be administered, this is done before steroid infiltration as a field block using 2% plain lignocaine. The syringe is attached by means of the Luer-Lock system and the desired amount of corticosteroid is aspirated. The needle is inserted into a proximal part of the scar and pretunneling is carried out using a fan-shaped approach (Fig. 1, above). At the end of each phase of pretunneling, the needle is withdrawn gently until the beveled tip remains just inside the scar. The plunger is depressed, releasing the required amount of contents, indicated by the pretunneled area becoming pale (Figs. 1, below, and (2). The needle is withdrawn and, in large scars, advanced to the distal boundary of the pale area. Step 3 is repeated until the entire scar is uniformly pale. For very large or long scars, longer needles are available that allow larger areas to be pretunneled following each insertion of the needle. Fig. 1.: (Above) Pretunneling of a keloid scar located on the back. (Below) Scar during injection. The tip of the needle is withdrawn so as to lie just beneath the skin and a small amount of steroid is infiltrated. The lesion becomes uniformly pale, confirming even distribution of the steroid.Fig. 2.: A larger scar in the axilla. A larger area is pretunneled and infiltrated through a single needle insertion point. The needle is reinserted at the edge of the pale area and step 3 is repeated until the entire scar is infiltrated.The presented technique builds on these modifications and introduces the concept of pretunneling scars before administration of corticosteroids. Although it is possible to pretunnel with a dental syringe, we found that the narrow-gauge dental needle was on occasion not sufficiently robust to pretunnel effectively and that it was easily deviated within the tough scar tissue. We demonstrate how a locked system can be constructed using readily available equipment and, in combination with pretunneling, an easier and more even distribution can be achieved. Ahid Abood, M.R.C.S. Alan Phipps, F.R.C.S.(Plast.) Department of Plastic, Reconstructive and Burns Surgery Pinderfields Regional Burns Center Wakefield, United Kingdom

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